ROCK2 Inhibition With Belumosudil (KD025) for the Treatment of Chronic Graft-Versus-Host Disease

PURPOSE

The rho-associated coiled-coil-containing protein kinase-2 (ROCK2) signaling pathway regulates the Th17/regulatory T cells balance and controls profibrotic pathways. Selective ROCK2 inhibition with belumosudil (KD025) may offer a novel approach to the management of chronic graft-versus-host disease (cGVHD).

PATIENTS AND METHODS

A phase IIa, open-label, dose-finding study of belumosudil enrolled 54 patients with cGVHD who had received one to three prior lines of therapy (LOTs). The primary end point was overall response rate (ORR).

RESULTS

The median time from cGVHD diagnosis to enrollment was 20 months. Seventy-eight percent of patients had severe cGVHD, 50% had ≥ 4 organs involved, 73% had cGVHD refractory to their last LOT, and 50% had received ≥ 3 prior LOTs. With an overall median follow-up of 29 months, the ORR (95% CI) with belumosudil 200 mg once daily, 200 mg twice daily, and 400 mg once daily was 65% (38% to 86%), 69% (41% to 89%), and 62% (38% to 82%), respectively. Responses were clinically meaningful, with a median duration of response of 35 weeks, and were associated with quality-of-life improvements and corticosteroid (CS) dose reductions. CS treatment was discontinued in 19% of patients. The failure-free survival rate was 76% (62% to 85%) and 47% (33% to 60%) at 6 and 12 months, respectively. The 2-year overall survival rate was 82% (69% to 90%). Belumosudil was well-tolerated, with low rates of cytopenia. There were no unexpected adverse events and no apparent increased risk of infection, including cytomegalovirus infection and reactivation.

CONCLUSION

Belumosudil treatment resulted in a high ORR and overall survival rate and demonstrated quality-of-life improvements, CS dose reductions, and limited toxicity. Data from the study indicated that belumosudil may prove to be an effective therapy for patients with treatment-refractory cGVHD.

Epidemiology and Treatment of Chronic Graft-versus-Host Disease Post-Allogeneic Hematopoietic Cell Transplantation: A US Claims Analysis

Chronic graft-versus-host disease (cGVHD) is a complication of hematopoietic cell transplantation (HCT). Although the clinical outcomes of cGVHD are well documented, few studies have assessed treatment practices outside of clinical trials. The present study aimed to quantify the prevalence of cGVHD, examine provider prescribing patterns, and evaluate the healthcare cost and resource utilization (HCRU) in a US cGVHD population. We analyzed anonymized claims from the Medicare Fee-for-Service (FFS) 5% sample for beneficiaries enrolled between 2013 and 2016 and PharMetrics commercial 2013 to 2018 databases to identify cGVHD in allogeneic HCT recipients. cGVHD was identified based on International Classification of Diseases Ninth/Tenth Revision diagnosis codes for cGVHD or unspecified GVHD with a first diagnosis >180 days post-HCT or a maintained unspecified GVHD diagnosis for >12 months postindex of unspecified GVHD diagnosis. Longitudinal and line of therapy (LOT) analyses were based on the PharMetrics dataset for 2013 to 2018. Healthcare costs were calculated by adding the inpatient, outpatient, and pharmacy insurer and beneficiary paid amounts for the commercially insured population. Total HCRU was assessed using the number of inpatient and outpatient visits following the initial cGVHD diagnosis. In 2016, the projected prevalence of cGVHD in the United States based on the Medicare FFS and PharMetrics commercial databases was 14,017 individual patients. Within 3 years after undergoing allogeneic HCT, 42% of patients developed cGVHD; 66% of the cGVHD patients had a prior diagnosis of acute GVHD. The majority of cGVHD patients received at least one systemic therapy; 71% and 47% of cGVHD patients progressed to a second and third LOT, respectively. A total of 24 unique therapeutic agents and more than 150 combinations were used in the second and third LOTs. Corticosteroids and corticosteroid combination therapy were the most common forms of treatment across all examined LOTs. Furthermore, the most commonly used agents in the first LOT, second LOT, and third LOT were corticosteroids only, calcineurin inhibitors only, and corticosteroids only, respectively. In the 12 months postdiagnosis, cGVHD patients had an average of 21.0 cGVHD-related inpatient and outpatient visits (2.8 inpatient and 18.2 outpatient visits). A significant proportion of allogeneic HCT recipients continue to develop cGVHD, and despite advances in the understanding of cGVHD, corticosteroids remain the mainstay of therapy. Patients often progress beyond the first LOT, at which time the utilization of systemic therapies is highly variable, demonstrating the need for evidence-based treatment approaches.

Efficacy and safety of carfilzomib regimens in multiple myeloma patients relapsing after autologous stem cell transplant: ASPIRE and ENDEAVOR outcomes

Autologous stem cell transplantation (ASCT) is a standard treatment for eligible multiple myeloma (MM) patients, but many patients will relapse after ASCT and require subsequent therapy. The proteasome inhibitor carfilzomib is approved for relapsed or refractory MM (RRMM). In phase 3 trials, carfilzomib-based regimens (ASPIRE, carfilzomib-lenalidomide-dexamethasone; ENDEAVOR, carfilzomib-dexamethasone) demonstrated superior progression-free survival (PFS) compared with standard therapies for RRMM (ASPIRE: lenalidomide-dexamethasone; ENDEAVOR, bortezomib-dexamethasone). This subgroup analysis of ASPIRE and ENDEAVOR evaluated outcomes according to prior ASCT status. In total, 446 patients in ASPIRE and 538 in ENDEAVOR had prior ASCT. Median PFS was longer for carfilzomib-based regimens vs non-carfilzomib-based regimens for patients with prior ASCT (ASPIRE: 26.3 vs 17.8 months (hazard ratio (HR)=0.68); ENDEAVOR: not estimable vs 10.2 months (HR=0.61)), those with one prior line of therapy that included ASCT (ASPIRE: 29.7 vs 17.8 months (HR=0.70); ENDEAVOR: not estimable vs 11.2 months (HR=0.46)), and those without prior ASCT (ASPIRE: 26.4 vs 16.6 months (HR=0.76); ENDEAVOR: 17.7 vs 8.5 months (HR=0.43)). Overall response rates also favored the carfilzomib-based regimens. No new safety signals were detected. This analysis suggests that carfilzomib-based treatment may lead to improvement in PFS and response rates regardless of prior transplant status. Further evaluation is warranted.

Cost-effectiveness of adding carfilzomib to lenalidomide and dexamethasone in relapsed multiple myeloma from a US perspective

OBJECTIVE

To assess the economic value of carfilzomib (Kyprolis), this study developed the Kyprolis Global Economic Model (K-GEM), which examined from a United States (US) payer perspective the cost-effectiveness of carfilzomib-lenalidomide-dexamethasone (KRd) versus lenalidomide-dexamethasone (Rd) in relapsed multiple myeloma (RMM; 1-3 prior therapies) based on results from the phase III ASPIRE trial that directly compared these regimens.

METHODS

A partitioned survival model that included three health states of progression-free (on or off treatment), post-progression, and death was developed. Using ASPIRE data, the effect of treatment regimens as administered in the trial was assessed for progression-free survival and overall survival (OS). Treatment effects were estimated with parametric regression models adjusting for baseline patient characteristics and applied over a lifetime horizon. US Surveillance, Epidemiology and End Results (1984-2014) registry data were matched to ASPIRE patients to extrapolate OS beyond the trial. Estimated survival was adjusted to account for utilities across health states. The K-GEM considered the total direct costs (pharmacy/medical) of care for patients treated with KRd and Rd.

RESULTS

KRd was estimated to be more effective compared to Rd, providing 1.99 life year and 1.67 quality-adjusted life year (QALY) gains over the modeled horizon. KRd-treated patients incurred $179,393 in total additional costs. The incremental cost-effectiveness ratio (ICER) was $107,520 per QALY.

LIMITATIONS

Extrapolated survival functions present the greatest uncertainty in the modeled results. Utilities were derived from a combination of sources and assumed to reflect how US patients value their health state.

CONCLUSIONS

The K-GEM showed KRd is cost-effective, with an ICER of $107,520 per QALY gained against Rd for the treatment of patients with RMM (1-3 prior therapies) at a willingness-to-pay threshold of $150,000. Reimbursement of KRd for patients with RMM may represent an efficient allocation of the healthcare budget.

Use of cannabinoids in cancer care: palliative care

All too often neglected, maximal quality improvement in the setting of life-limiting illness and noxious symptomatology is a worthy medical, public health, and humanitarian goal [...]

Chemically selective polymer substrate based direct isotope dilution alpha spectrometry of Pu

Quantification of actinides in the complex environmental, biological, process and waste streams samples requires multiple steps like selective preconcentration and matrix elimination, solid source preparations generally by evaporation or electrodeposition, and finally alpha spectrometry. To minimize the sample manipulation steps, a membrane based isotope dilution alpha spectrometry method was developed for the determination of plutonium concentrations in the complex aqueous solutions. The advantages of this method are that it is Pu(IV) selective at 3M HNO3, high preconcentration factor can be achieved, and obviates the need of solid source preparation. For this, a thin phosphate-sulfate bifunctional polymer layer was anchored on the surface of microporous poly(ethersulfone) membrane by UV induced surface grafting. The thickness of the bifunctional layer on one surface of the poly(ethersulfone) membrane was optimized. The thickness, physical and chemical structures of the bifunctional layer were studied by secondary ionization mass spectrometry (SIMS), scanning electron microscopy (SEM) and SEM-EDS (energy-dispersive spectroscopy). The optimized membrane was used for preconcentration of Pu(IV) from aqueous solutions having 3-4M HNO3, followed by direct quantification of the preconcentrated Pu(IV) by isotope dilution alpha spectrometry using (238)Pu spike. The chemical recovery efficiency of Pu(IV) was found to be 86±3% below Pu(IV) loading capacity (1.08 μg in 2×1 cm(2)) of the membrane sample. The experiments with single representative actinides indicated that Am(III) did not sorb to significant extent (7%) but U(VI) sorbed with 78±3% efficiency from the solutions having 3M HNO3 concentration. However, Pu(IV) chemical recovery in the membrane remained unaffected from the solution containing 1:1000 wt. proportion of Pu(IV) to U(VI). Pu concentrations in the (U, Pu)C samples and in the irradiated fuel dissolver solutions were determined. The results thus obtained were found to be in good agreement with those obtained by conventional alpha spectrometry, biamperometry and thermal ionization mass spectrometry.

Isotopic correlation for 242Pu composition prediction: Multivariate regresssion approach

Multivariate regression calibration using multiple linear regression (MLR), principle component regression (PCR) and partial least squares regression (PLSR) algorithm was performed on ²³⁸Pu, ²³⁹Pu, ²⁴⁰Pu and ²⁴¹Pu atom% abundances to predict ²⁴²Pu isotopic abundance. The MLR algorithm was found to be the best among these three algorithms. The effect of ²³⁸Pu composition on the ²⁴²Pu abundance prediction was found to be small but significant especially for achieving high accuracy of <0.5%. PCR and PLSR generated nearly identical results and were inferior to the MLR results. A comparison of MLR results with those obtained by employing seven previously reported empirical methods revealed far superior prediction capability of MLR model. Among the seven empirical models, the best prediction capability was found for Bignan correlation containing ²³⁸Pu isotopic data. The study clearly demonstrates that the production of ²³⁸Pu and ²⁴²Pu has some small correlation and the use of ²³⁸Pu in isotopic correlation for ²⁴²Pu prediction is important to get accurate results.

Immature teratoma of the nose and paranasal sinuses masquerading as bilateral nasal polyposis: a unique presentation

Teratomas are tumors of multipotent cells derived from all three germ cell layers and recapitulate normal organogenesis. Teratomas are hypothesized to arise by misplacement of multipotent germ cells. Teratoma is usually developmental and sometimes congenital neoplasm which displays both solid and cystic components with gross and microscopic differentiation into a wide variety of tissues representative of all three germ layers--ectoderm, mesoderm and endoderm. We are describing a case which was initially diagnosed as bilateral nasal polyposis clinically but histopathology report came out to be immature teratoma. This case is being reported to make aware all ENT surgeons of such unique presentation of sinonasal teratomas as such presentation of these tumors has not been reported in literature previously, and hence teratomas should be considered in the differential diagnosis of nasal polyposis in future.

Assessment of baseline characteristics, glycemic control and oral antidiabetic treatment in Asian patients with diabetes: The Registry for Assessing OAD Usage in Diabetes Management (REASON) Asia study

BACKGROUND

To assess baseline characteristics, glycemic control, and treatment with oral antidiabetic drugs (OAD) in type 2 diabetes mellitus (T2DM) patients.

METHODS

This multinational, observational study recruited patients ≥ 21 years of age who were newly diagnosed and/or treated with OAD monotherapy for <6 months but were inadequately controlled. In cross-sectional phase, data on demographics, medical history, diabetic complications and comorbidities, OAD treatment, glycosylated hemoglobin (HbA1c), and fasting blood glucose (FBG) were collected. In longitudinal phase evaluating 6-month follow-up of sulfonylurea (SU)-treated patients, additional data on reasons for not achieving HbA1c targets were collected.

RESULTS

Of 1487 patients (mean [± SD] age 52.0 ± 11.6 years; 46.7% men; mean BMI 25.8 ± 4.4 kg/m(2) ) recruited, 75.9% were newly diagnosed, 73.3% had central obesity, 43.8% had hypertension, and 60.5% had dyslipidemia. The mean HbA1c was 9.8 ± 2.4%, and the mean FBG was 11.3 ± 4.3 mmol/L. At T0 (baseline) and T6 (month 6 visit), 99.8% (n=1066) and 97.1% (n=830) patients received SU, respectively. There was decrease from T0 to T6 in mean HbA1c (10.2% vs 7.3%, respectively; P<0.0001) and mean FBG (12.0 vs 7.6 mmol/L, respectively; P<0.0001). Number of patients with HbA1c <7% increased from T0 (4.5%) to T6 (46.8%). Reasons for not achieving target HbA1c included poor diabetes education (50.7%), non-compliance to OADs (21.4%), and fear of hypoglycemia (19.7%).

CONCLUSION

Marked reductions in HbA1c and FBG are achievable in T2DM patients managed with OADs. However, patient education and compliance are important for achieving and maintaining treatment targets.

Evaluation of the oxidative stress in chronic alcoholics

AIM

The present study was conducted to assess the activity of Gamma Glutamyl Transferase (GGT) and its association with oxidative stress in alcoholics.

METHOD

Sixty male alcoholics with a history of alcohol abuse for more than five years were the subjects of this study. Twenty healthy male volunteers who matched in age and the socio-economic status, served as the control subjects.

RESULTS

GGT, reduced glutathione (GSH, a key intra-cellular antioxidant) and malondialdehyde (MDA, a marker of the oxidative stress) were assayed in the plasma of the two groups, and the results were statistically analyzed. The activity of the plasma GGT, known as a marker of Alcoholic Liver Disease (ALD); was significantly higher in the alcoholics as compared to that in the healthy controls.

CONCLUSION

There was a significant positive correlation between the enzyme activity and the plasma levels of MDA and this indicated that there was an increased release of this enzyme with enhanced oxidative damage, due to the generation of oxygen free radicals in the study group. There was a significantly increased level of MDA and a decrease in the level of GSH in the alcoholics as compared to those in the controls. Significant negative correlations between GGT and GSH, and between MDA and GSH were observed. The present study demonstrates that alcoholics have a compromised antioxidant defense system.

Genome-wide association study for type 2 diabetes in Indians identifies a new susceptibility locus at 2q21

Indians undergoing socioeconomic and lifestyle transitions will be maximally affected by epidemic of type 2 diabetes (T2D). We conducted a two-stage genome-wide association study of T2D in 12,535 Indians, a less explored but high-risk group. We identified a new type 2 diabetes-associated locus at 2q21, with the lead signal being rs6723108 (odds ratio 1.31; P = 3.32 × 10⁻⁹). Imputation analysis refined the signal to rs998451 (odds ratio 1.56; P = 6.3 × 10⁻¹²) within TMEM163 that encodes a probable vesicular transporter in nerve terminals. TMEM163 variants also showed association with decreased fasting plasma insulin and homeostatic model assessment of insulin resistance, indicating a plausible effect through impaired insulin secretion. The 2q21 region also harbors RAB3GAP1 and ACMSD; those are involved in neurologic disorders. Forty-nine of 56 previously reported signals showed consistency in direction with similar effect sizes in Indians and previous studies, and 25 of them were also associated (P < 0.05). Known loci and the newly identified 2q21 locus altogether explained 7.65% variance in the risk of T2D in Indians. Our study suggests that common susceptibility variants for T2D are largely the same across populations, but also reveals a population-specific locus and provides further insights into genetic architecture and etiology of T2D.

Oxidised LDL, HDL cholesterol, LDL cholesterol levels in patients of coronary artery disease

Coronary artery disease is a major cause of morbidity and has various risk factors. Lipid profile i.e. low HDL-cholesterol, high LDL cholesterol, high total cholesterol, high triglycerides playing important role in its causation. Recently interest has been shown in the oxidized fraction of LDL as one of the risk factors. In the present study 60 age and sex matched normal healthy individuals were taken as controls and 60 patients of CAD were taken. Cholesterol was measured by enzymatic method, HDL cholesterol by phosphotungstate precipitation method. Serum levels of LDL fraction of cholesterol was measured by a new and simpler method of precipitation. Result was expressed as mol/L of diene conjugates. It was observed that LDL cholesterol, VLDL cholesterol, total cholesterol, total cholesterol: HDL cholesterol, LDL cholesterol: HDL cholesterol were significantly raised and HDL cholesterol was significantly low in patients. (p<0.001). Though HDL cholesterol was significantly raised in females as compared to males in both the groups (p<0.001). Serum level of total cholesterol, oxidized LDL:HDL cholesterol were also raised significantly (p<0.05). The level of oxidized LDL showed an increasing trend in patients.

Antioxidant vitamins and chemoprevention

Free radicals play an important role in human carcinogenesis and the mechanism of their counteraction by antioxidant vitamins has been reviewed. It seems more likely that these vitamins work in concert rather than acting singly. Currently available data are compatible with the notion that these vitamins act as chemopreventives against some important cancers, e.g. carotenoids for lung cancer, ascorbic acid for salivary gland cancer, tocopherols for head and neck cancers etc. Thus, a greater consumption of fruits and vegetables should be encouraged as they are the natural sources of these chemopreventive, antioxidants along with other protective factors packaged by nature. However, much work still remains to be done to establish the role of antioxidant vitamins in carcinogenesis.

Hyperhomocysteinemia and cardiovascular disease: The nutritional perspectives

Several members of the vitamin B-complex family are known to participate in the normal metabolism of homocysteine (Hcy). Leaving aside the genetic determinants of hyperhomocysteinemia (HHC), the deficiencies of these vitamins can also result in HHC. The situation of sustained and long standing HHC is likely to be prevalent in population groups with low/average socio-economic status, geriatric population and alcohol abusers. If not corrected by supplementation, these population groups certainly are more vulnerable to develop atherosclerosis (AS) and subsequently, cardiovascular disease (CVD). Hyperhomocysteinemia per se and/or HHC-induced oxidative stress result(s) in chronic chemical endothelial injury/dysfunction, smooth muscle proliferation, prothrombotic state and oxidation of low density lipoproteins (LDL) leading to diverse cardiovascular complications. In the first decade of the new millennium, major research efforts would be directed towards understanding the basic mechanism of HHC-induced oxidative stress and the pathophysiology of HHC-induced CVD, culminating in the evolution of hitherto unknown therapeutic strategies such as nutriceuticals and oxidant-antidotes.

Megacystis, microcolon, intestinal hypoperistalsis syndrome and bilateral streak gonads

Megacystis, microcolon, intestinal hypoperistalsis is an uncommon condition presenting in neonatal age with features of intestinal obstruction and bladder evacuation abnormalities. We present here an infant girl with the diagnosis consistent with this entity.

Outbreak of Meningococcal Infection amongst Soldiers Deployed in Operations

BACKGROUND

Meningococcal infection may lead to life threatening meningitis and fulminant meningococcal sepsis. Sporadic cases of meningococcal infection have been reported in soldiers but no outbreak in soldiers has been reported earlier from India. This outbreak in soldiers serving in counter insurgency role under field setting was effectively controlled without compromising their operational commitment.

METHODS

This is an epidemiological investigation and control of an outbreak of meningococcal infection, bringing out the predisposing factors and highlighting the role of early diagnosis and management of cases. Mass chemoprophylaxis in contacts was used as an effective control measure in the absence of vaccine in this institution based outbreak.

RESULT

Out of a total of 17 cases reported, 14 presented as meningitis and three as meningococcemia. Two cases of meningococcemia ended fatally. Serogroup A of Neisseria meningitidis was responsible for this outbreak. Gross over- crowding was the predisposing factor.

CONCLUSION

An outbreak of meningococcal infection in soldiers deployed in counter- insurgency role was effectively contained using mass chemoprophylaxis in the absence of meningococcal vaccine.

Renal tuberculosis in infancy

We report a case of congenital renal tuberculosis in a 34-day-old child presenting as severe hematuria. Adequate antitubercular treatment may provide protection to fetus in subsequent pregnancies.

Meconium peritonitis presenting as abdominal calcification: three cases with different pathology

Intra-abdominal calcification is uncommon in newborns and has several causes of which meconium peritonitis is the most frequent. Three neonates with intra-abdominal calcification as a complication of meconium peritonitis are presented. The types of meconium peritonitis were cystic, meconium pseudocyst and meconium ascites. Two required surgical intervention. Meconium peritonitis should be considered in newborns with intra-abdominal calcification.

Blood glutathione levels in head and neck malignancies

Blood glutathione was estimated in fifty patients of head and neck cancer in the age group of 18-76 years and the results were compared with a group of normal healthy controls. Mean blood glutathione level was found to be significantly lowered in patients than the controls. Irrespective of the site, TNM classification, histopathology, and character of lesion, fall in blood glutathione was nearly same in all the patients. The mean level was significantly increased after radiotherapy when compared with the levels before radiotherapy. The decreased levels of GSH in-patients with head and neck cancer, observed in the present study, may be due to its increased utilization by the cells. The results suggest that patients with head and neck cancer have increased oxidative stress.

Laser-induced breakdown spectroscopy for simultaneous determination of Sm, Eu and Gd in aqueous solution

This paper reports studies on the determination of trace levels of samarium, europium and gadolinium in aqueous samples by laser-induced breakdown spectroscopy (LIBS). In this work, a membrane-based filter paper was used as a sample support for the liquid samples. The laser-induced plasma was produced in air at atmospheric pressure, using a pulsed Nd:YAG laser. Calibration standards and synthetic mixtures of these lanthanides were prepared using solutions prepared from respective high purity oxides. Linear calibration was obtained for Sm, Eu and Gd by normalizing the intensities of lanthanides emission lines with respective to C(I) 193.029 nm emission line. The concentrations of Sm, Eu and Gd were then determined in a solution containing a mixture of these lanthanides. The concentrations of individual lanthanides were obtained within 5% of the expected values. Limits of detection were found to be 1.3 ppmw (Sm), 1.9 ppmw (Eu) and 2.3 ppmw (Gd).

Use of faecal excretion function for quick estimation of initial and existing lung burden for occupational exposure control due to 239Pu for S-class of intake

Two functions namely initial lung deposition and lung retention per unit faecal excretion rate are constructed primarily based on the excretion pattern of four subjects exposed to (239)Pu. In the absence of initial clear knowledge about the class of compound inhaled, faecal to urine excretion ratio was used to infer the type of inhaled class. Trends in the urine and faecal data had suggested that the intake was due to mixed class of plutonium compound for each case. With the assumption of 1:1 mixture of plutonium M&S class inhaled compound, faecal excretion rates for only S-class intake were worked out. Uptake inferred based on their urinary data had suggested it to be of similar level within 40% of uncertainty for 5 microm particle size distribution. Data, all the four cases, were pooled for analysis citing the similar level of intake, particle size distribution, nature and pattern of work. The function obtained was tested for S-class lung retention and faecal excretion rate value. These functions are handy tool for estimating initial lung burden and lung retention value for low level of S-class plutonium intake based on subject faecal analysis data.

Derivation and validation of a urinary excretion function for plutonium based on occupational exposure

Formation of a three-component urinary excretion function using the data of occupational exposure cases is described. Measurement results of plutonium inhalation from two subjects over 6000 and 2500 d are used in the derivation of this function. The three-component excretion function obtained is U(t) = 0.0008e(-0.0566(t)) + 0.00009e(-0.0042(t)) + 0.00004e(-0.00008(t)). The function is therefore proposed as a reliable basis to make an uptake assessment for operational control for mixed class of plutonium dominated by M-class chronic exposure.

Determination of 243Am by pulse shape discrimination liquid scintillation spectrometry

Alpha specific activity of 243Am was determined using pulse shape discrimination in liquid scintillation spectrometry. 238Pu, 36Cl and 239Np (purified from 243Am) were used for obtaining the spillover of alpha/beta particles into the beta/alpha channels, respectively. Synthetic mixtures of 241Am/243Am were prepared. Using the alpha-specific activity, weights of the stock solutions used and the half-life of 241Am and 243Am isotopes, the expected 241Am/243Am atom ratios in the mixtures were determined and compared with those obtained by thermal ionization mass spectrometry (TIMS). An agreement of about 1% was obtained between the 241Am/243Am atom ratios determined by the two methods. This shows that liquid scintillation counting with pulse shape discrimination can be used for 243Am determination with an accuracy better than 1%.

Benign rheumatoid nodules

Rheumatoid nodules occur usually in advanced seropositive rheumatoid arthritis, signifying poor prognosis. However rarely rheumatoid nodules can be encountered in patients with no antecedent evidence of arthritis. Herein a case of an arthritic benign rheumatoid nodules is described.

Role of supravital staining of urine sediment and bright field microscopy in diagnosis of acute renal failure in bedside medicine

BACKGROUND

An early accurate etiological categorization of acute renal failure (ARF) into acute glomerulonephritis (AGN), acute tubular necrosis (ATN) and acute interstitial nephritis (AIN) is very important in clinical medicine.

METHODS

To evaluate the efficacy of a simple, cheap supravital staining method developed in our laboratory, we examined urine of 32 cases of ARF at their initial presentation in oliguric phase, which were later biopsied. The stain consisted of 1% crystal violet and 0.5% safranin in normal saline. The coverslip preparations of coded and stained urine sediments were examined under ordinary bright field microscope (BFM) by two independent observers.

RESULTS

The renal biopsy showed 12 cases of AGN, 12 ATN and 8 AIN. The diagnosis could be predicted by supravital staining method in 75% cases with 95% uniformity among two observers with a sensitivity of 85.7% for AGN followed by AIN (80%) and ATN (75%).

CONCLUSION

Thus this simple supravital staining technique can be used with ordinary BFM for accurate urine sediment analysis in cases of ARF in bedside medicine.

Immune system activation by CDDP and "poly-plat"

Murine peritoneal macrophages, human fibroblasts and human ovarian teratocarcinoma cells were treated with CDDP (10 micrograms/ml) and "poly-plat" (10 micrograms/ml) for 2 h and cultured for 2-96 h. After "poly-plat" treatment macrophages developed cytoplasmic extensions much faster and secreted higher levels of interleukin-2 (IL-2), compared to CDDP. "Poly-plat" treated human fibroblasts demonstrated a significant release of IL-2 (138 pg/ml), compared to CDDP (64 pg/ml) or the untreated normal cells (31 pg/ml) after 8 h. Correspondingly there was a 53% increase in cells after "poly-plat" treatment compared to only 37% after CDDP. However, human ovarian teratocarcinoma cells didn't show any significant increase in IL-2 levels after "poly-plat" treatment and there was instead a decrease of 15% in cell numbers at 8 h. Based on our studies, we propose that "poly-plat" is more effective in activation of the macrophages and human fibroblasts in terms of IL-2, but not so with human ovarian teratocarcinoma cells.

Synergistic immunosuppression by candida in HIV infection: a cytokine based analysis

Candida is a common opportunistic pathogen in HIV infection and is regarded a signal infection for progression to AIDS. Cytokine imbalances between Th1/Th2 groups have been described in both candida and HIV infections. A study was undertaken to assess the role of candida in furthering immunosuppression in HIV infection based on cytokine levels and CD4 cell counts. 30 Indian subjects were enrolled; 10 HIV positive patients with and 10 without mucosal candidiasis and 10 age matched controls. Th1 cytokines; interleukin (IL) 2, IL 12 and interferon (IFN) gamma, Th2 cytokines; IL 4, IL 6, IL 10 and tumor necrosis factor (TNF) alpha with CD 4 cell counts were estimated using ELISA in all subjects. CD4 cell counts were reduced in both patient groups as compared to controls; significantly more in patients with both HIV and candida infections. There was a decrease in Th1 cytokine levels in all patients; lower levels of Th1 cytokines were seen in patients with both infections. Among the Th2 cytokines, there was a significant increase in the levels of IL 6, IL 10 and TNF alpha in both patient groups; IL 10 and TNF alpha values were significantly raised in patients with dual HIV and candida infections as compared to the other patients. There was no difference in IL 4 values across the subject groups. A positive correlation between CD4 cell counts and Th1 cytokine levels and a negative correlation with Th2 cytokines were noted; these were stronger in patients with both HIV and candidiasis. Thus, there was a Th1/Th2 cytokine imbalance with CD4 cell count reduction in all HIV infected patients, which was more pronounced in patients with both infections. It can be concluded that, owing to the depressed CD4 cell count and Th1 response and increased Th2 cytokines in patients with both candidiasis and HIV as compared to patients with only HIV candidiasis may have a synergistic immunosuppressive effect with HIV in patients with dual infections.

Immunocytochemical and in situ hybridization studies of gastrin after cisplatin treatment

Cisplatin treatment (9 mg/kg) causes bloating of the stomach, an increase in gastric acid, and ulceration in rats. Gastrin, a gut peptide, plays an important role in regulating gastric acid production. To study the role of gastrin in this increased gastric acid production after cisplatin treatment, male Wistar rats (100-150 g) were treated with cisplatin (9 mg/kg) in five divided doses over 5 consecutive days. The rats were sacrificed 1, 6, 10, or 15 days after the last treatment. As measured by immunocytochemistry, in situ hybridization, Northern blot, and dot-blot techniques, gastrin was found to be below detectable limits just 1 day after cisplatin treatment. However, 10-15 days after the last injection, the levels for both gastrin and its mRNA gradually recovered to normal. Northern blot studies showed that decreased somatostatin mRNA parallels the changes of gastrin and its mRNA. These results suggest that after cisplatin treatment the increased gastric acid production in rat stomach is independent of gastrin. This decrease of gastrin production is not under the influence of somatostatin, which also decreased after cisplatin treatment.

Histochemical and morphological identification of Kupffer cells activated by cisplatin

Cisplatin is a potent anti-cancer agent which has been shown to activate Kupffer cells. These activated macrophages demonstrate an increase in extensions, lysosomes, and peroxisomes increasing their anti-tumor activity. Wistar rats were treated with cisplatin (9 mg/kg) and sections of liver were excised for light and electron microscopic analysis at 1, 6, 15, and thirty days post treatment. Non-specific esterase staining was used to differentiate Kupffer cells using light microscopy, morphologic criteria were used for TEM analysis. Liver sections taken 6 days post treatment showed the greatest number of activated macrophages, with the highest degree of activation. Interaction between natural killer cells and Kupffer cells was only seen 6 days post treatment. These results show that cisplatin's ability to enhance the immune system requires several days post treatment to reach maximum potency.

Enhanced immune system activation after treatment with novel antineoplastic platinum agents

"Poly-plat", SSP, and SAP are second generation analogs of cisplatin (CDDP) with higher efficacy and potency. In order to understand the mechanism of action of these compounds, isolated murine peritoneal macrophages were treated with "poly-plat", SSP, or SAP (5 micrograms/ml) for 2 h. Treated macrophages demonstrated an increase in the number of lysosomes, but only "poly-plat" and SSP treated macrophages were stimulated to form the cytoplasmic extensions so very characteristic of cisplatin after 2 h and 24 h post-treatment. SAP showed cytoplasmic extensions only after 24 h post-treatment, and demonstrated a back to the normal discoid form when viewed at 24 h post-treatment. When drug treated macrophages were co-incubated with S180 tumor cells, cytoplasmic extensions of the macrophages developed contacts, and cytoplasmic continuity with the tumor cells, and a subsequent transfer of lysosomes from macrophage to tumor cell was observed after only 2 h of co-incubation. After 24 h of co-incubation, lysis of S180 cells was achieved. Analysis of the tissue culture supernatants collected from "poly-plat", SSP, and SAP treated macrophages demonstrated the enhanced activity of interleukin-1 alpha of over 400 pg/ml after 2 h post-treatment, compared to only 300 pg/ml with cisplatin 24 h post-treatment. However, only SSP demonstrated an increase in TNF-alpha activity (2000 pg/ml) after 2 h post-treatment, which is comparable to that of cisplatin. Based on our observations we propose that "poly-plat", SSP, and SAP activate various cytolytic factors of the immune system better, than cisplatin.

Immune system activation by cisplatin and its analog 'poly-plat': an in vitro and in vivo study

Swiss Webster mice treated with bolus injections of 'poly-plat' (10 mg/kg) show increased macrophage activation after 2 and 12 days when isolated in cultures. Such macrophages demonstrate an increase in the number of lysosomes and cytoplasmic extension formation with enhanced cytokine (interleukin-1alpha) activity. In addition, peripheral blood smears demonstrated an increase in lymphocytes and monocytes compared to cisplatin-treated animals. These results show that 'poly-plat' activates the immune system more effectively than cisplatin both in vitro and in vivo.

Role of calcium in modulation of toxicities due to cisplatin and its analogs: a histochemical approach

Cisplatin, carboplatin and paclitaxel (taxol) are potent antineoplastic agents with associated toxicities, especially gastrointestinal and nephrotoxicity that are their dose-limiting factors in clinical oncology. In an attempt to elucidate their mechanism(s) of toxicity, liver and kidney tissues from normal and drug treated rats and dogs were evaluated for changes in various dehydrogenase and non-specific lipase enzymes. Histochemically, cisplatin treatment induced an inhibition of all the enzymes studied except glucose-6-phosphate dehydrogenase and non-specific lipases, where there was a significant increase. Supplemental treatments with calcium [1 ml of 1.3% CaCl2/day in rats and 2.50 mg (150000 USP units) ergocalciferol plus 1000 mg of elemental calcium as TUMS 500 (EffeCal)/day in dogs] seem to protect against severe gastrointestinal toxicity and nephrotoxicity.

Effects of cisplatin and taxol on inducible nitric oxide synthase, gastrin and somatostatin in gastrointestinal toxicity

Cisplatin (9 mg/kg) or taxol (20 mg/kg) treatment of Wistar rats produced a sharp decrease in inducible nitric oxide synthase (iNOS) and gastrin in the pyloric region of the stomach, and an increase in iNOS and somatostatin in the pancreatic islets. Nitric oxide (NO) functions as a relaxation factor in the smooth muscle of the muscularis mucosa while gastrin plays an important role in the gastroprotection of the mucosa through NO. It is proposed that a decline of the iNOS and gastrin after cisplatin or taxol treatments is related to distention of the stomach, and possibly nausea and vomiting. Hyperglycemia and glucose intolerance after cisplatin treatment may be caused by increases of somatostatin and iNOS in the pancreatic islets. Combination therapy with cisplatin and taxol seems to ameliorate various toxicities due to these two individual drugs.

Activation of murine peritoneal macrophages after cisplatin and taxol combination

Cisplatin and paclitaxel are potent antineoplastic agents. Their distinctly different mechanisms of action have prompted laboratory and clinical research into their use in combination therapies. Murine peritoneal macrophages treated with cisplatin and paclitaxel in combination elicit an increase in their number of lysosomes. Drug-treated macrophages, when co-incubated with sarcoma 180 cells, establish cytoplasmic contact and transfer lysosomes into tumor cells causing tumor cell lysis. In addition, analysis of tissue culture supernatants show increased levels of interleukin-1alpha and tumor necrosis factor-alpha. Our study shows that cisplatin and paclitaxel in combination enhance elements of the immune system with greater efficacy and potency than when used alone.